Rethinking Living Donor Kidney Transplantation Through a Healthcare System Lens

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Since the first successful living donor kidney transplant that took place in the United States in 1954 between twin brothers, the field has expanded to living directed unrelated kidney donation, single-paired and chain-paired exchanges, and nondirected donations. Accepting more medically complex (e.g., donors with treated hypertension) or older donors (e.g., aged >70 years) has further allowed for viable increases in living kidney donation. Rates of living kidney donor transplantation (LDKT) worldwide vary among healthcare systems in different geographic regions; moreover, the proportion of living-to-deceased donor kidney transplant is highly variable.¹ In some countries, kidney transplantation occurs exclusively through living donors. Regardless of expanding acceptable relationships between donors and recipients, and utilizing donors who are medically complex, the net growth in living donor kidney transplants over time is slow and comprise about 39% of kidney transplants worldwide.²

Universally, LDKT affords recipients superior outcomes, including planned surgical interventions, immediate allograft function, and the longest posttransplant graft survival compared to any type of deceased donor transplantation.^3,4 Despite this compelling evidence, complexities in delivering care across multiple settings within large healthcare systems act as a barrier to achieving optimal access to and improving rates of LDKT.

In this issue of KI Reports, Horton and coauthors examined how health system level provisions for LDKT differ across 3 Canadian provinces, including British Columbia (BC), Ontario and Quebec.⁵ Seventy-five percent of Canada’s population and >70% of patients with end-stage kidney disease reside in these provinces. However, the rates of LDKT represented in these areas are below, at, and above the national average in Canada. They acknowledged the federally mandated universal healthcare in Canada and emphasize the differences in regulations and delivery of services in the different provinces. Uniquely, the study team conducted a qualitative investigation using case studies, semi structured interviews and focus groups to describe the healthcare system attributes that facilitate living kidney donation in high and low performing transplant centers. The healthcare system attributes were organized along a 4-level, nested framework that had patients at its core with outer ring nests, including care teams, organizations, and environments.

The authors found several key attributes of high performing health systems related to living kidney donation. Macro-level agencies and structures such as renal programs and organ donation organizations or advocacy groups with provincial oversight were more likely to lead to effective LDKT processes. The success of the BC Agency and BC transplant with majority of the total transplants closely followed by Ontario was reported and compared to the low number of observed transplants in Quebec. Lack of similar organized macro-level structure and oversite to promote LDKT in nephrology clinics was a salient observation. The provinces with the most transplants had more funding to deploy human resources ensuring transplant coordinators in nephrology clinics and social workers for psychosocial support. Overall, hospital run initiatives employed in Quebec compared to macro-level interventions did not yield direct resource to support LDKT in nephrology clinics due to competing priorities. Although all 3 provinces employed means to improve access to LDKT, projects done at provincial levels in BC and Ontario yielded more impact.

They also identified opportunities for improvement in all 3 provinces: competition of living donor kidney transplant with other treatments for kidneys such as dialysis, and coordination between transplant centers and nephrology clinics. They suggest a multidisciplinary approach in a real-world setting and structures in place at all facets to address barriers to LDKT.

Provincial initiatives to improve access to LDKT were noted in all 3 provinces emphasizing the impact of projects done at provincial levels in Ontario and BC versus in Quebec with hospital-based initiatives limited to transplant program to enhance collaboration across systems. Emphasizing community of practices such as enabling sharing ideas for interorganizational learning was found to be effective.

Overall, this study employs a pragmatic approach to identifying the impact of targeting roadblocks to transplantation at all levels. What adaptations within health systems are necessary to directly impact LDKT? (Figure 1). On the recipient side, patients with end-stage kidney disease are often waitlisted only after starting dialysis and more uncommonly receive preemptive living donor kidney transplants. Early referral and education about kidney transplant and the benefits of receiving a living donor transplant are imperative. There is evidence that the competing risk of death or delisting for transplant candidates occurs as soon as 24 months after being placed on the waiting list in some cases (e.g., diabetics and older age).⁶ The ability to mitigate these competing risks relies on early referral and education to consider potential living donors, thus shortening waiting time and dialysis vintage. From the donor perspective, living kidney donation is the ultimate altruistic act among patients who are typically very healthy, and have few previous interactions with the healthcare system. Our responsibility as a kidney community is to respect a donor’s time; limit emotional, physical, and mental strain; offer transparency; and provide significant support throughout the evaluation process. Protecting employment and insurability as well as preventing financial hardships for actual donors can be accomplished through health policies and professional societies.

Figure 1.

Key adaptations across healthcare systems to increase living donor kidney transplantation.

Building expertise and capacity regarding LDKT can be accomplished using practice-based interventions with frontline caregivers. These interventions may include care teams assessing patient activation toward living donation, identifying social networks, and offering longitudinal support for potential living donor recipients.⁷ Adopting a collaborative community-academic model to disseminate evidence-based practices as has been done to reduce disparities in access to kidney transplant wait listing is another feasible strategy to test for living donor kidney transplant.⁸

In the work by Horton et al.,⁵ less attention is given to the environmental level of the proposed systems framework. Racial, socioeconomic, and gender disparities in access to LDKT are prevalent. Understanding the contexts in which living donor kidney transplants are being performed is a key factor in addressing these disparities. Strategies to improve rates of kidney transplant need to be culturally appropriate; focusing on religious, spiritual, and health beliefs, social determinants of health, and systemic racism.⁹

The status quo for chronic disease management within large complex healthcare systems tends to align with the processes of care that are easiest for patients and their care teams to navigate. In kidney medicine, and more specifically, for patients with end-stage disease, access to dialysis and deceased donor transplant is the status quo. As a kidney community, we have an obligation to carefully adapt our systems to increase rates of LDKT for our patients who stand to benefit from it most.

Disclosure

AMH reports advisory or leadership roles as follows: Cleveland Minority Organ and Tissue Transplant Education Program (MOTTEP) Advisory Board Co-Chair, Chairperson for IPRO ESRD Network of the Ohio River Valley Medical Review Board, Member of the Medical Director Advisory Council for The National Forum of ESRD Networks. All the other authors declared no competing interests.